Senior Claim Benefit Specialist in Ga Work From Home

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines. Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues. Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience. Additional Responsibilities - Reviews pre‑specified claims and those that exceed specialist adjudication authority or processing expertise. - Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost‑containment measures to support accurate claim adjudication. - Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures. - Identifies and reports potential overpayments, underpayments, and other claim irregularities. - Performs claim rework calculations as needed. - Trains and mentors as needed to enhance team performance and technical proficiency. - Conducts outbound calls to obtain required information for claims or reconsideration requests. Required Qualifications - Minimum of 18 months of medical claim processing experience with a health insurance payor or third‑party administrator. - Proven

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Job Description Carries out and facilitates Scrum events, removing impediments, promoting collaboration, supporting the Product Owner, and driving continuous improvement. Ensures the effective implementation of the Scrum framework, creating a conducive environment for the team's success, and fostering a culture of collaboration and continuous learning. What you will do Counsels scrum master teams on agile principles and values to support self-organization, continuous learning, and continuous improvement. Interprets the agile metrics and reporting framework in order to track and report key information and monitor team progress. Designs and develops industry-leading process evaluation tools to assess the application of scrum principles in team processes. Develops actionable insights from analytics and reports on team productivity, velocity, and quality. Develops the stakeholder communication strategy to gather and incorporate feedback into process improvements. Handles various responsibilities to facilitate the scrum process and support the scrum team. Implements sharing and documentation systems to facilitate sharing through wikis, documentation platforms, or knowledge management tools. Instructs team members on agile values, principles, and practices to help stakeholders and product owners understand the benefi